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Clinical Lab Table of Contents
Preface Information
Desk Reference Guide Acronyms and Abbreviations
Program Information
General Program Information Program Background and Objectives Provider Agreement and Professional Standards Payer of Last Resort Program Reimbursement Payment in Full Incorrect Payment Claim Submission Timeliness Medical and Other Record Content Requirements Record Retention Requirements Provider Participation and Enrollment Participation Enrollment Re-certification Suspension or Termination Electronic Media Claims (EMC) Enrollment Program Communication and Services Written Correspondence Telephone Inquiries Provider Training On-Site Visits Publications Direct Deposit Recipient Eligibility and Identification Benefit Levels Categorically Needy Medically Needy Qualified Medicare Beneficiaries (QMBs) EPSDT Identification Card Altered ID Cards and Other Abuses Inmates Ineligible for Medical Assistance Program Benefits Recipient Eligibility Verification System (REVS) Flexible Test of Income Spend-Down Liability (SDL) Determining Payment When a Spend-Down Amount Is Applied Third Party Liability (TPL) for Medical Expenses Claims Filing Refunds Resulting From Other Insurance Co-insurance and Deductible Services Utilization Review (SURS) Review of Services Utilized RIte Care Program Overview Participating Health Plans Eligibility Enrollment Copayment and Premiums Scope of Services
Claim Management Information
General Billing Information Typed and Handwritten Claims Submitting Copies Attachments for Claims Provider Signature Correct Postage Using a Billing Company Requesting Change of Address/Change of Status Non-Providers Ordering Claim Forms Timeliness Requirements Hand-Delivered Paper and Electronic Claims Claim Form Order Card Provider Manual Order Form Out-of-State and Emergency Claims Medical Services Provided Outside of Rhode Island Prior Authorization Exceptions to Prior Authorization Circumstances In Which Medical Care Is Provided Payments Timeliness Border Communities Prior Authorization (PA) PA Instructions Claim Correction Form (CCF) CCF Instructions Remittance Advice (RA) Banner Page Paid, Denied, Claims in Process Adjusted Claims Financial Items TPL and Medicare Earnings Data and Error Messages Paid Claim Adjustments and Refunds Single and Multiple Adjustment Request Forms Information Required Attachments Single Adjustment Request Form Instructions Multiple Adjustment Request Form Instructions Refunds or Recoupments of Paid Claims Underpayment
Medical Coverage Policies
Please note that policy and procedures are subject to change. Refer to your provider update bulletins regarding your provider type.
Claims Billing Guidelines Covered Services Unlisted Procedures Individual and Panel Test Billing Limitations / Special Requirements Identify Referring Physician Reference Laboratory Non-Covered Services Handling Fee Venipuncture Interpretation Patient Liability Provider Participation Guidelines Recertification Reimbursement Guidelines Medicare/Medicaid Crossover
Claim Preparation Instructions
CMS 1500 Form Filing Instructions Clinical Laboratory Services – CSM 1500 Claim Form
Error Status Codes
ESC Code List (English)
Explanation of Benefits (EOB) Codes
EOB Codes and Messages List (English) EOB Codes and Messages List (Spanish)
Appendix - Third Party Liability Carrier and Coverage Codes
Third Party Liability (TPL) Carrier Codes Third Party Liability (TPL) Carrier Codes (PDF Format) Third Party Liability (TPL) Coverage Codes
